Basic Information
| Provider Information | |||||||||
| NPI: | 1871516799 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PCC COMMUNITY WELLNESS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 LAKE ST | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603022606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083830113 | ||||||||
| FaxNumber: | 7083831378 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 LAKE ST | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603022606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083830113 | ||||||||
| FaxNumber: | 7083831378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | URSO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 7083839786 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.